RA Messages for November 2, 2004

PHARMACY PROVIDERS, PLEASE NOTE!!!

IF YOU ARE UNSURE ABOUT THE COVERAGE OF A DRUG PRODUCT, PLEASE CONTACT THE PBM HELP DESK AT 1-800-648-0790

PLEASE MAKE THE FOLLOWING CHANGES TO THE APPENDIX A: 

DRUG DOSAGE  STRGTH MAC EFF DATE 
ACETAMIN/CAFF/BUTALB TABLET 500-40-50 0.68700 10/28/2004 
AMOXICILLIN TRIHYD. CAPSULE 250MG 0.06750 10/28/2004
AMOXICILLIN TRIHYD. CAPSULE 500MG 0.13020  10/28/2004
ATENOLOL TABLET 50MG 0.10580 10/28/2004
ATENOLOL TABLET 100MG 0.19430 10/28/2004 
BETAMETHASONE DIPROP. LOTION 0.05%  0.15000  10/28/2004
BETAMETHASONE VALERATE LOTION 0.1% 0.21192  10/28/2004
BISOPROLOL FUM/HCTZ TABLET 2.5-6.25MG 1.02600 10/28/2004
BISOPROLOL FUM/HCTZ TABLET 5-6.25MG 1.02600  10/28/2004 
CAPTOPRIL TABLET 12.5MG 0.02320 10/28/2004 
CAPTOPRIL TABLET  50MG  0.03900 10/28/2004
CAPTOPRIL TABLET 100MG 0.10800 10/28/2004
CEFACLOR SUSP RECON 125MG/5ML 0.09800 10/28/2004
CEFACLOR SUSP RECON 187MG/5ML  0.14700 10/28/2004
CHLORHEXADINE GLUCON. LIQUID 1.25MG/ML 0.01090 10/28/2004
CHLORZOXAZONE  TABLET 500MG 0.07570 10/28/2004 
CIMETIDINE TABLET 200MG 0.13130 10/28/2004 
CIMETIDINE TABLET 400MG 0.10710 10/28/2004 
CLOMIPRAMINE HCL CAPSULE 75MG  0.66230 10/28/2004 
CODEINE PHOS/ACETAMIN TABLET 60-300MG 0.38330  10/28/2004
D-AMPHETAMINE SULF TABLET 10MG  0.34350  10/28/2004
DIAZEPAM TABLET 10MG  0.05730  10/28/2004
DIPHENOXYLATE HCL/ATROP TABLET   2.5MG 0.10880 10/28/2004
DOXYCYCLINE HYCLATE CAPSULE 50MG  0.13170  10/28/2004
ENALAPRIL MALEATE  TABLET 2.5MG 0.43340 10/28/2004
ERYTHROMYCIN BASE OINT 5MG/G 1.07140 10/28/2004
ESTRADIOL  TABLET 1MG 0.21751 10/28/2004
FAMOTIDINE TABLET 20MG 0.15000 10/28/2004
FAMOTIDINE TABLET 40MG 0.30000 10/28/2004
FLECAINIDE ACET. TABLET  50MG   0.86100 10/28/2004 
FLECAINIDE ACET. TABLET  100MG 1.40700 10/28/2004 
FLECAINIDE ACET. TABLET  150MG 1.93280 10/28/2004 
FLUOCINONIDE CREAM-TP 0.05% 0.07900 10/28/2004 
FLUOCINONID/EMOLLIENT CREAM-TP 0.05%  0.24530 10/28/2004 
FLURBIPROFEN TABLET 100MG 0.24380 10/28/2004 
GENTAMICIN SULF DROPS 0.3%  0.57000 10/28/2004 
GLIPIZIDE TABLET 10MG  0.11920 10/28/2004 
HALOPERIDOL LACTATE ORAL CONC 2MG/ML 0.13690 10/28/2004 
HYDROCOD.BIT/ACETAMIN TABLET 5-500MG 0.08330 10/28/2004 
HYDROCODONE/HOMATROPINE SYRUP 5-1.5MG/5  OFF MAC 10/28/2004
ISOSORBIDE DINITRATE  TAB SUBL 2.5MG OFF MAC 10/28/2004
KETOPROFEN CAPSULE 50MG OFF MAC 10/28/2004
KETOPROFEN CAPSULE 75MG OFF MAC 10/28/2004
LIDOCAINE HCL SOLUTION  20MG/ML 0.03150 10/28/2004
LITHIUM CARBONATE  CAPSULE 300MG 0.13500  10/28/2004
MECLIZINE HCL  TABLET 25MG 0.04200 10/28/2004
METFORMIN HCL  TABLET 1000MG  0.45970  10/28/2004
METOPROLOL TARTR  TABLET 100MG 0.06900 10/28/2004
MIRTAZAPINE TABLET 15MG 1.63000 10/28/2004
MIRTAZAPINE TABLET 30MG 1.67750 10/28/2004
MIRTAZAPINE TABLET 45MG 1.71000 10/28/2004
NEOMY SULF/GRAM D/POLY DROPS     - 2.02500 10/28/2004
OXAZEPAM  CAPSULE  15MG 0.57090 10/28/2004
OXYCODONE HCL/ACETAMIN CAPSULE  5-500MG 0.22480 10/28/2004
PERGOLIDE MESYLATE TABLET 1MG  3.48720 10/28/2004
POTASSIUM CHLORIDE TABLET SA 8MEQ  0.08930 10/28/2004
RIMANTADINE HCL TABLET 100MG 1.51200 10/28/2004
SULFAMETHOX/TRIMETHO TABLET 800-160MG 0.14540  10/28/2004
TAMOXIFEN CITRATE TABLET  10MG  0.97130 10/28/2004
TAMOXIFEN CITRATE TABLET  20MG  1.94250  10/28/2004
TICLOPIDINE HCL TABLET 250MG 0.27320  10/28/2004
TIZANIDINE HCL  TABLET 2MG  0.64990 10/28/2004
TIZANIDINE HCL  TABLET 4MG     0.78990  10/28/2004
TOBRAMICIN SULFATE  DROPS 0.3% 0.67200 10/28/2004
TRIAMCINOLONE ACET. CREAM  0.025% 0.06562 10/28/2004
TRIAMCINOLONE ACET. CREAM  0.1% 0.04690 10/28/2004
TRIAMTERENE/HCTZ   TABLET 37.5-25MG 0.16830 10/28/2004
VERAPAMIL HCL TABLET 40MG  0.15090 10/28/2004

    PLEASE FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN INCORRECTLY PAID

NOTICE TO DENTAL PROVIDERS - NEW DENTAL CLAIM FORM REQUIREMENTS

EFFECTIVE 1/1/2005, THE 2002 AMERICAN DENTAL ASSOCIATION CLAIM FORM AND THE 2002, 2004 AMERICAN DENTAL ASSOCIATION CLAIM FORM WILL BECOME THE ONLY HARDCOPY DENTAL CLAIM FORMS ACCEPTED FOR MEDICAID PRIOR AUTHORIZATION AND REIMBURSEMENT OF SERVICES PROVIDED IN THE EPSDT, EDSPW, AND ADULT DENTURE PROGRAMS. FURTHER INFORMATION REGARDING THIS REQUIREMENT WILL BE PROVIDED IN THE SEPT/OCT 2004 ISSUE OF THE PROVIDER UPDATE AND IS CURRENTLY AVAILABLE ON THE WWW.LAMEDICAID.COM WEBSITE. SHOULD YOU HAVE ANY QUESTIONS REGARDING THIS MATTER, YOU MAY CONTACT UNISYS PROVIDER RELATIONS AT (225) 924-5040 OR (800) 473-2783 OR THE MEDICAID DENTAL PRIOR AUTHORIZATION UNIT AT (504) 619-8589.